anomalies and curiosities of medicine-第148部分

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　authors　know　of　an　unreported　case　in　which　a　man　running　in　the　street　touched　his　hand　to　a　hitching　block　he　was　passing；　a　ring　on　one　of　his　fingers　caught　in　the　hook　of　the　block；　and　tore　off　the　finger　with　the　attached　tendon　and　muscle。　There　is　a　similar　instance　of　a　Scotch　gentleman　who　slipped；　and；　to　prevent　falling；　he　put　out　his　hand　to　catch　the　railing。　A　ring　on　one　of　his　fingers　became　entangled　in　the　railing　and　the　force　of　the　fall　tore　off　the　soft　parts　of　the　finger　together　with　the　ring。

The　older　writers　mentioned　as　a　curious　fact　that　avulsion　of　the　arm；　unaccompanied　by　hemorrhage；　had　been　noticed。　Belchier；　Carmichael；　and　Clough　report　instances　of　this　nature；　and；　in　the　latter　case；　the　progress　of　healing　was　unaccompanied　by　any　uncomfortable　symptoms。　In　the　last　century　Hunezoysky　observed　complete　avulsion　of　the　arm　by　a　cannon…ball；　without　the　slightest　hemorrhage。　The　Ephemerides　contains　an　account　of　the　avulsion　of　the　hand　without　any　bleeding；　and　Woolcomb　has　observed　a　huge　wound　of　the　arm　from　which　hemorrhage　was　similarly　absent。　Later　observations　have　shown　that　in　this　accident　absence　of　hemorrhage　is　the　rule　and　not　the　exception。　The　wound　is　generally　lacerated　and　contused　and　the　mouths　of　the　vessels　do　not　gape；　but　are　twisted　and　crushed。　The　skin　usually　separates　at　the　highest　point　and　the　muscles　protrude；　appearing　to　be　tightly　embraced　and　almost　strangulated　by　the　skin；　and　also　by　the　tendons；　vessels；　and　nerves　which；　crushed　and　twisted　with　the　fragments　of　bone；　form　a　conical　stump。　Cheselden　reports　the　history　of　a　case；　which　has　since　become　classic；　that　he　observed　in　St。　Thomas'　Hospital　in　London；　in　1837。　A　miller　had　carelessly　thrown　a　slip…knot　of　rope　about　his　wrist；　which　became　caught　in　a　revolving　cog；　drawing　him　from　the　ground　and　violently　throwing　his　body　against　a　beam。　The　force　exerted　by　the　cog　drawing　on　the　rope　was　sufficient　to　avulse　his　whole　arm　and　shoulder…blade。　There　was　comparatively　little　hemorrhage　and　the　man　was　insensible　to　pain；　being　so　dazed　and　surprised　he　really　was　unconscious　of　the　nature　of　his　injury　until　he　saw　his　arm　in　the　wheel。

According　to　Billroth　the　avulsion　of　an　arm　is　usually　followed　by　fatal　shock。　Fischer；　however；　relates　the　case　of　a　lion…tamer　whose　whole　left　arm　was　torn　from　the　shoulder　by　a　lion；　the　loss　of　blood　being　very　slight　and　the　patient　so　little　affected　by　shock　that　he　was　able　to　walk　to　the　hospital。

Mussey　describes　a　boy　of　sixteen　who　had　his　left　arm　and　shoulder…blade　completely　torn　from　his　body　by　machinery。　The　patient　became　so　involved　in　the　bands　that　his　body　was　securely　fastened　to　a　drum；　while　his　legs　hung　dangling。　In　this　position　he　made　about　15　revolutions　around　the　drum　before　the　motion　of　the　machinery　could　be　effectually　stopped　by　cutting　off　the　water　to　the　great　wheel。　When　he　was　disentangled　from　the　bands　and　taken　down　from　the　drum　a　huge　wound　was　seen　at　the　shoulder；　but　there　was　not　more　than　a　pint　of　blood　lost。　The　collar…bone　projected　from　the　wound　about　half　an　inch；　and　hanging　from　the　wound　were　two　large　nerves　（probably　the　median　and　ulnar）　more　than　20　inches　long。　He　was　able　to　stand　on　his　feet　and　actually　walked　a　few　steps；　as　his　frock　was　opened；　his　arm；　with　a　clot　of　blood；　dropped　to　the　floor。　This　boy　made　an　excellent　recovery。　The　space　between　the　plastered　ceiling　and　the　drum　in　which　the　revolutions　of　the　body　had　taken　place　was　scarcely　7　1/2　inches　wide。　Horsbeck's　case　was　of　a　negro　of　thirty…five　who；　while　pounding　resin　on　a　12…inch　leather　band；　had　his　hand　caught　between　the　wheel　and　band。　His　hand；　forearm；　arm；　etc。；　were　rapidly　drawn　in；　and　he　was　carried　around　until　his　shoulder　came　to　a　large　beam；　where　the　body　was　stopped　by　resistance　against　the　beam；　fell　to　the　floor；　and　the　arm　and　scapula　were　completely　avulsed　and　carried　on　beyond　the　beam。　In　this　case；　also；　the　man　experienced　little　pain；　and　there　was　comparatively　little　hemorrhage。　Maclean　reports　the　history　of　an　accident　to　a　man　of　twenty…three　who　had　both　arms　caught　between　a　belt　and　the　shaft　while　working　in　a　woolen　factory；　and　while　the　machinery　was　in　full　operation。　He　was　carried　around　the　shaft　with　great　velocity　until　his　arms　were　torn　off　at　a　point　about　four　inches　below　the　shoulder…joint　on　each　side。　The　patient　landed　on　his　feet；　the　blood　spurting　from　each　brachial　artery　in　a　large　stream。　His　fellow…workmen；　without　delay；　wound　a　piece　of　rope　around　each　bleeding　member；　and　the　man　recovered　after　primary　amputation　of　each　stump。　Will　gives　an　excellent　instance　of　avulsion　of　the　right　arm　and　scapula　in　a　girl　of　eighteen；　who　was　caught　in　flax…spinning　machinery。　The　axillary　artery　was　seen　lying　in　the　wound；　pulsating　feebly；　but　had　been　efficiently　closed　by　the　torsion　of　the　machinery。　The　girl　recovered。

Additional　cases　of　avulsion　of　the　upper　extremity　are　reported　by　Aubinais；　Bleynie；　Charles；　George；　James；　Jones；　Marcano；　Belchier；　Braithwaite；　and　Hendry。　

Avulsion　of　the　Lower　Extremity。The　symptoms　following　avulsion　of　the　upper　extremity　are　seen　as　well　in　similar　accidents　to　the　leg　and　thigh；　although　the　latter　are　possibly　the　more　fatal。　Horlbeck　quotes　Benomont's　description　of　a　small　boy　who　had　his　leg　torn　off　at　the　knee　by　a　carriage　in　motion；　the　child　experienced　no　pain；　and　was　more　concerned　about　the　punishment　he　expected　to　receive　at　home　for　disobedience　than　about　the　loss　of　his　leg。　Carter　speaks　of　a　boy　of　twelve　who　incautiously　put　the　great　toe　of　his　left　foot　against　a　pinion　wheel　of　a　mill　in　motion。　The　toe　was　fastened　and　drawn　into　the　mill；　the　leg　following　almost　to　the　thigh。　The　whole　left　leg　and　thigh；　together　with　the　left　side　of　the　scrotum；　were　torn　off；　the　boy　died　as　a　result　of　his　injuries。

Ashurst　reported　to　the　Pathological　Society　of　Philadelphia　the　case　of　a　child　of　nine　who　had　its　right　leg　caught　in　the　spokes　of　a　carriage　wheel。　The　child　was　picked　up　unconscious；　with　its　thigh　entirely　severed；　and　the　bone　broken　off　about　the　middle　third；　about　three　inches　higher　the　muscles　were　torn　from　the　sheaths　and　appeared　as　if　cut　with　a　knife。　The　great　sciatic　nerve　was　found　hanging　15　inches　from　the　stump；　having　given　way　from　its　division　in　the　popliteal　space。　The　child　died　in　twelve　hours。　One　of　the　most　interesting　features　of　the　case　was　the　rapid　cooling　of　the　body　after　the　accident　and　prolongation　of　the　coolness　with　slight　variations　until　death　ensued。　Ashurst　remarks　that　while　the　cutaneous　surface　of　the　stump　was　acutely　sensitive　to　the　touch；　there　was　no　manifestation　of　pain　evinced　upon　handling　the　exposed　nerve。

With　reference　to　injuries　to　the　sciatic　nerve；　Kuster　mentions　the　case　of　a　strong　man　of　thirty；　who　in　walking　slipped　and　fell　on　his　back。　Immediately　after　rising　to　his　feet　he　felt　severe　pain　in　the　right　leg　and　numbness　in　the　foot。　He　was　unable　to　stand；　and　was　carried　to　his　house；　where　Kuster　found　him　suffering　great　pain。　The　diagnosis　had　been　fracture　of　the　neck　of　the　femur；　but　as　there　was　no　crepitation　and　passive　movements　caused　but　little　pain；　Kuster　suspected　rupture　of　the　sciatic　nerve。　The　subsequent　history　of　the　case　confirmed　this　diagnosis。　The　patient　was　confined　to　bed　six　weeks；　and　it　was　five　months　afterward　before　he　was　able　to　go　about；　and　then　only　with　a　crutch　and　a　stick。

Park　mentions　an　instance　of　rupture　of　the　sciatic　nerve　caused　by　a　patient　giving　a　violent　lurch　during　an　operation　at　the　hip…joint。

The　instances　occasionally　observed　of　recovery　of　an　injured　leg　after　extensive　severance　and　loss　of　substance　are　most　marvelous。　Morton　mentions　a　boy　of　sixteen；　who　was　struck　by　one　of　the　blades　of　a　reaping　machine；　and　had　his　left　leg　cut　through　about　1　1/4　inches　above　the　ankle…joint。　The　foot　was　hanging　by　the　portion　of　skin　corresponding　to　the　posterior　quarter　of　the　circumference　of　the　leg；　together　with　the　posterior　tibial　vessels　and　nerves。　These　were　the　only　structures　escaping　division；　although　the　ankle…joint　itself　was　intact。　There　was　comparatively　little　hemorrhage　and　no　shock；　a　ligature　was　applied　to　the　vessels；　the　edges　of　the　wound　were　drawn　together　by　wire　sutures；　and　the　cut　surfaces　of　the　tibia　were　placed　in　as　good　apposition　as　possible；　although　the　lower　fragment　projected　slightly　in　front　of　the　upper。　The　wound　was　dressed　and　healing　progressed　favorably；　in　three　months　the　wound　had　filled　up　to　such　an　extent　that　the　man　was　allowed　to　go　on　crutches。　The　patient　was　discharged　in　five　months；　able　to　walk　very　well；　but　owing　to　the　loss　of　the　function　of　the　extensor　tendons　the　toes　dragged。

Washington　reports　in　full　the　case　of　a　boy　of　eleven；　who；　in　handing　a　fowling　piece　across　a　ditch；　was　accidentally　shot。　The　contents　of　the　gun　were　discharged　through　the　leg　above　the　ankle；　carrying　away　five…sixths　of　the　structureat　the　time　of　the　explosion　the　muzzle　of　the　gun　was　only　two　feet　away　from　his　leg。　The　portions　removed　were　more　than　one　inch　of　the　tibia　and　fibula　（irregular　fractures　of　the　ends　above　and　below）；　a　corresponding　portion　of　the　posterior　tibial　muscle；　and　the　long　flexors　of　the　great　and　small　toes；　as　well　as　the　tissue　interposed　between　them　and　the　Achilles　tendon。　The

anterior　tibial　artery　was　fortunately　uninjured。　The　remaining　portions　consisted　of　a　strip　of　skin　two　inches　in　breadth　in　front　of　the　wound；　the　muscles　which　it　covered　back　of　the　wound；　the　Achilles　tendon；　and　another　piece　of　skin；　barely　enough　to　cover　the　tendon。　The　wound　was　treated　by　a　bran…dressing；　and　the　limb　was　saved　with　a　shortening　of　but　1　1/2　inches。

There　are　several　anomalous　injuries　which　deserve　mention。　Markoe　observed　a　patient　of　seventy…two；　who　ruptured　both　the　quadriceps　tendons　of　each　patella　by　slipping　on　a　piece　of　ice；　one　tendon　first　giving　way；　and　followed　almost　immediately　by　the　other。　There　was　the　usual　depression　immediately　above　the　upper　margin　of　the　patella；　and　the　other　distinct